The Health Insurance Portability and Accountability Act of 1998 (HIPAA) is a federal program that requires that all medical records and other individual identifiable health information used or disclosed by me in any form, whether electronically, on paper, or orally are kept properly confidential. This act gives you, the client, significant rights to understand and control how you health information is used. HIPAA provides penalties for covered entitle that misuse personal health information.


As required by HIPAA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health information.


I may use and disclose your medical records only for each of the following purposes:


  • Treatment – the provision, coordination, or management of health care and related services of one or more health care providers. Examples of this are coordinating your care with your physician or psychiatrist or arranging emergency treatment.
  • Payment  - such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visits to your insurance company for payment.
  • Health Care Operations - the business aspects of running my practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be consulting an attorney to ensure that I am in compliance with applicable laws.


I may also create and distribute de- identified health information by removing all references to individually identifiable information.


I may contact you to provide appointment reminders or information about treatment alternatives or other health –related benefits and services that may be of interest to you.


Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your authorization.


You have the following rights with respect to your protected health information (PHI), which you can exercise by presenting a written request to me:


  • The right to request restrictions of certain uses and disclosures of PHI, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. I am, however, not required to agree to a requested restriction. If I do agree to a restriction, I must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of PHI from me by alternative means or at alternative locations.
  • The right to inspect and copy your PHI.
  • The right to amend your PHI.
  • The right to receive an accounting disclosure of PHI.
  • The right to obtain a paper copy of this notice from me upon request.

I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI.


This notice has been in effect since April 14, 2003, and I am required to abide by the terms of the Notice of Privacy Practices currently in effect. I reserve the right to change the terms of my Notice of Privacy Practices and to make the new notice provisions effect for all PHI that I maintain. I will post, and you may request, a written copy of a revised Notice of Privacy Practices from my office.


You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with me, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of my office. I will not retaliate against you for filing a complaint.


Please contact me for more information.

Elaine R. Poncelet, LICSW  (401) 294-9500.


For more information about HIPAA or to file a complaint:


The U.S. Dept. of Health and Human Services,

Office of Civil Rights,

200 Independence Ave., S.W.

Washington, D.C.  20201; (202) 619-0257; Toll Free: 1-877-696-6775.

Elaine R.Poncelet,LICSW 

Privacy Policy

HIPAA Notice of Privacy Practices